Defense & Barriers 2: Pruritus Treatment Flashcards
TOPICAL therapy…
3 main goals?
7 options for drug treatment w/ examples & when to use them?
- DRYING AGENTS/ASTRINGENTS
–> keep dry things moist, keep moist things dry
–> example = ALUMINUM ACETATE/SULFATE; good for HOT SPOTS (ACUTE, MOIST, PYOTRAUMATIC DERMATITIS) - PROTECTANTS
–> help KEEP MOISTURE IN
–> example 1 = REDUCING TRANSEPIDERMAL WATER LOSS, such as with OILS (lanolin, safflower)
–> example 2 = HYGROSCOPIC agents that take up and RETAIN moisture = glycerin, propylene glycol, polyethylene glycol, urea, L-rhamnose - ANTIHISTAMINES
–> example = DIPHENHYDRAMINE - TOPICAL ANESTHETICS
–> usually NOT GREAT FOR PRURITUS bc SHORT-ACTING & cannot PENETRATE STRATUM CORNEUM
–> examples = LIDOCAINE & PRAMOXINE - TOPICAL STEROIDS/GLUCOCORTICOIDS
–> used more often for OTITIS
–> example 1 = TRIAMCINOLONE, best for PEDAL PRURITUS
–> example 2 = MOMETASONE, best for HYPERPLASTIC/INFLAMED EAR CANALS - NON-STEROIDAL IMMUNOMODULATORS
–> used more for LOCALIZED IMMUNE-MEDIATED DISEASES IN DOGS THAN PRURITUS, usually pruritus too WIDESPREAD
–> examples = CALCINEURIN INHIBITORS like TACROLIMUS & PIMECROLIMUS - Products RICH in SPHINGOLIPIDS & CERAMIDES
–> used to CORRECT LIPID CONTENT
BETAMETHASONE
= what is it?
WHAT DRUG SHOULD YOU NOT USE WITH IT & WHY?
= TOPICAL STEROID treatment for PRURITUS
**DO NOT USE WITH AMINOGLYCOSIDES like GENTAMICIN –> causes CUTANEOUS ATROPHY
side effect of LONG-TERM glucocorticoid topical use in DOGS?
what does it usually start as?
which animal is this the biggest problem in?
= SYSTEMIC HYPERGLUCOCORTICOIDISM LIKELY!!
Usually starts with CUTANEOUS ATROPHY, CARTILAGE (especially in ears) will DETERIORATE & FLOP OVER
Bigger problem in CATS
NON-STEROIDAL anti-pruritic…
3 drug options?
for FIRST one include mechanism of action, what 3 chemicals it contains, issue with dosing, synergistic effects
for SECOND one, what it’s mostly used for, advantage, 3 disadvantages including generations w/ 3 drug examples, contraindications, eosinophils?
for THIRD one, what it is & 2 things it does, advantages/disadvantages, what TYPE of drug we should get
- ESSENTIAL FATTY ACIDS
–> more specifically, OMEGA-3 FATTY ACIDS (fish oil) that contain EPA, DHA, GLA
–> MECHANISM of action? = incorporated into CELL MEMBRANES of KERATINOCYTES and COMPETES WITH ENZYMES that BREAK DOWN AA so that products are ANTI-INFLAMMATORY LTs/PGs
–> DOSING is UNLABELED = likely higher than you think
–> works SYNERGISTICALLY w/ VITAMIN E & ANTIHISTAMINES - ANTIHISTAMINES
–> mostly used for PREVENTION/MAINTENANCE of RESPIRATORY DZ & URTICARIA
–> ADVANTAGES = SAFE & INEXPENSIVE
–> DISADVANTAGES?
- NOT much evidence for ANTI-PRURITIC effects
- FIRST generation (diphenhydramine, benedryl) can cause DROWSINESS
- SECOND generation is NON-SEDATING but LESS EFFECTIVE IN DOGS
–> CETIRIZINE = ZYRTEC
–> FEXOFENADINE = ALLEGRA
–> can also inhibit EOSINOPHIL migration
**CONTRAINDICATION = DON’T USE IN PATIENTS WITH GLAUCOMA DUE TO ANTI-CHOLINERGIC EFFECTS - VITAMIN E
–> = POTENT ANTIOXIDANT that DECREASES PROSTAGLANDIN PRODUCTION and DECREASES IgE levels in ATOPIC patients
–> ADVANTAGES = CHEAP, OTC, SAFE, SYNERGISTIC
–> DISADVANTAGES = VITAMIN MARKET is NOT WELL REGULATED
–> should always get D-ALPHA-TOCOPHEROL (NATURAL Vitamin E), NOT DL-ALPHA-TOCOPHEROL bc NOT ABSORBED WELL IN DOGS
SYSTEMIC GLUCOCORTICOIDS for pruritus…
fill in the blank:
steroids hit ____ ___ of the ___ ___, which explains why it works well for pruritus caused by ____, ____, and ___
method of action? (1 big one, 3 subs)
indications? (2)
goals? (2)
ORAL drug examples by NAME ONLY? (5, first 2 separated by species)
EVERY ASPECT, ATOPIC CASCADE, ALLERGY, PARASITISM, INFECTION
method of action?
= MODIFY TRANSCRIPTION/expression of GENES that end up…
1. DECREASING PRO-INFLAMMATORY CYTOKINES, ENZYMES & EICOSANOIDS
2. INCREASING ANTI-INFLAMMAORY CYTOKINES, ENZYMES & EICOSANOIDS
3. INHIBITION of INFLAMMATORY CELL TRAFFICKING & TISSUE ADHESION MOLECULES
indications?
1. SHORT TAPERS for ACUTE FLARES (“itch buster dose”), just worry about PU/PD
2. MAINTENANCE of SEASONAL ATOPY with DURATION LESS THAN 4 MONTHS, good for financially challenged clients
goals?
1. LEAST possible FREQUENCY at the LEAST possible DOSE by using CONCURRENT THERAPIES…
–> antihistamines, EFAs, vitamin E, allergen-specific immunotherapies
2. AVOID using with OTHER IMMUNOSUPPRESSING DRUGS
drug names?
1. PREDNISONE (dogs)
2. PREDNISOLONE (cats)
3. METHYLPREDNISOLONE
4. TRIAMCINOLONE
5. DEXAMETHOSONE
OPTIONS for SYSTEMIC GLUCOCORTICOIDS for pruritus in SA…
SEPARATE by FIRST (3), SECOND (1), and THIRD-LINE (1) CHOICES?
describe how long they act, potency, if they need to be compounded
FIRST line?
1. PREDNISONE (dogs)
2. PREDNISOLONE (cats, livers do not convert prednisone well)
3. METHYLPREDNISONE
= SHORTEST-ACTING and LEAST PRONE TO HPA-AXIS SUPPRESSION (dogs) and DIABETES MELLITUS (cats)
–> but 5X the cost of regular prednisone/prednisolone
SECOND line?
1. TRIAMCINOLONE
–> must be COMPOUNDED so not used as often
–> LONGER-ACTING and HIGHER POTENCY, but INCREASED SIDE EFFECT POTENTIAL
THIRD line?
1. DEXAMETHOSONE
–> **THIRD CHOICE FOR CATS but CAUTION IN DOGS due to HPA SUPPRESSION
–> LONGEST-ACTING and HIGHEST POTENCY
for dogs that have become REFRACTORY to ORAL PREDNISONE, what drug should they try next? WHY THIS DRUG?
TRIAMCINOLONE
if we want to stick with an ORAL STEROID, then this is a good option!
options for PARENTERAL/INJECTABLE steroids…
most often used in WHAT species?
2 drugs?
(first one: 2 uses, side effects, frequency, caution in dogs/cats
second one: 3 uses, benefit in comparison, 2 cautions)
most often used in CATS
drugs?
1. METHYLPREDNISOLONE ACETATE (Depo-Medrol)
–> USE = for PROBLEMATIC EOSINOPHILIC GRANULOMAS & LIP ULCERS
–> SIDE EFFECTS = can last 3+ MONTHS if given IM/SQ & often OUT-LAST CLINICAL EFFECTS
–> FREQUENCY = clinical effects will DECREASE with repeated usage
–> CAUTION
- DO NOT USE IN DOGS = ADDISON’S
- CAUTION in cats = check BLOOD GLUCOSE before administration
- TRIAMCINONLONE ACETONIDE (Vetalog)
–> USE = for INTRA-LESIONAL TREATMENT, such as…
- SINGLE EOSINOPHILIC GRANULOMAS
- STENOTIC ear canals
- AURAL hematomas (after blood evacuated)
–> BENEFIT = SHORTER-ACTING
–> CAUTION
- sticks around 10-14 days AFTER injection
- POTENT HPA AXIS SUPPRESSION
LEUKOTRIENE INHIBITORS… (finish the sentence, easy)
HAVE NO EFFICACY FOR ATOPIC DERMATITIS IN DOGS ACCORDING TO LITERATURE
ALLERGEN-SPECIFIC IMMUNOTHERAPY (allergen vaccines)…
indications? (2)
disadvantages? (1)
advantages? (2)
method of action? (2)
formulation of vaccines? (2)
frequency of dosing/route of administration? (3)
indications?
1. AD patients that CANNOT be managed with NON-STEROIDAL or NON-IMMUNOSUPPRESSIVE regimens
2. dogs LESS THAN 5 YEARS OLD or CLINICAL SIGNS FOR LESS THAN 5 YEARS
disadvantages?
1. results can take 4-18 months, NOT INSTANT GRATIFICATION
advantages?
1. 50% of pets will NOT NEED ADDITIONAL MEDICATIONS, other 50% will NEED LOWER DOSES
2. good responders will NOT GET SECONDARY INFECTIONS
method of action? = IMPROVE T REGULATORY CELL FUNCTION
1. INDUCES Treg cells to SWITCH CYTOKINE profile from Th2 –> Th1
2. PREVENTS ATOPIC CASCADE by INDUCING PRODUCTION of IgG-BLOCKING Abs that bind to SPECIFIC ALLERGENS
formulation of vaccines?
1. LIMITED to 12-15 allergens PER VIAL
2. 2 VIALS MAXIMUM
frequency of dosing/route of administration?
1. SUBCUTANEOUS (SCIT) = every 7-30 days depending on PATIENT RESPONSE
2. SUBLINGUAL (SLIT) = every 12-24 HOURS, CANNOT MISS A DOSE
3. INTRA-LYMPHATIC = first 4 injections given ONCE per MONTH IN-CLINIC, then WEEKLY SQ
NON-steroidal immunomodulators BY NAME ONLY (4)
- MAROPITANT (cerenia)
- CALCINEURIN INHIBITORS (cyclosporine)
- JANUS KINASE INHIBITORS (apoquel)
- MONOCLONAL anti-IL-31 Abs (cytopoint)
MAROPITANT
what class of drugs?
alternative name?
what it is?
method of action for itch?
in cats vs. dogs?
called CERENIA
NON-steroidal immunomodulator
= NEUROKININ-1 RECEPTOR (NK-1R) ANTAGONIST to help PREVENT EMESIS & MOTION SICKNESS in both dogs/cats
method of action?
Helps prevent SUBSTANCE P from working = pruritogenic neurokinine that is elevated in ATOPIC SKIN
in cats vs. dogs?
CATS = given ONCE DAILY for ANTI-EMESIS
DOGS = NO CLINICAL EFFICACY, worth trying but EXPENSIVE
cyclosporine
what class of drugs? (2)
product? (include vet and human formula names)
dosages in dogs/cats?
contraindications? (1, 3 drug examples)
class?
1. NON-steroidal immunomodulator
2. CALCINEURIN INHIBITOR
product?
= MODIFIED CYCLOSPORINE A in DOGS/CATS
–> veterinary formulation = ATOPICA, human = NEORAL
dosages?
1. DOGS = 5 mg/kg ONCE daily, CAN COMBINE WITH KETACONAZOLE to REDUCE FREQUENCY & DOSE IN LARGE DOGS
2. CATS = 7 mg/kg, **DO NOT COMBINE WITH KETACONAZOLE (hepatotoxicity)
contraindications?
= drugs that INDUCE CYTOCHROME P450 MICROSOMAL ENZYMES
1. phenobarbital
2. chloramphenicol
3. rifampin
MONITORING for cyclosporine use?
what class of drugs? (2)
adverse clinical signs? (3, how to prevent first one and duration for last one)
possible diseases? (4)
what testing recommended PRIOR to administration in cats? (1)
**what test for OUTDOOR cats & what does it mean when POSITIVE or NEGATIVE?
class?
1. NON-steroidal IMMUNOMODULATOR
2. CALCINEURIN INHIBITOR
adverse clinical signs?
1. NAUSEA/VOMITING (common)
–> Can freeze capsules (drug gets out of stomach and into intestines before release) or administer with anti-emetic
2. DIARRHEA
3. GINGIVAL HYPERPLASIA/NASO-DIGITAL or PEDAL HYPERKERATOSIS = LONG-TERM USE
diseases?
1. DIABETOGENIC = monitor blood glucose for 6-12 mos in AT-RISK pets
2. SECONDARY INFECTIONS (UTIs) = monitor urine culture ONLY IF SIGNS
3. SECONDARY NEOPLASIA = concern for long-term therapy
4. HEPATIC/RENAL TOXICITY = RARE IN DOGS/CATS, high doses/compromised patients
For CATS…
1. Recommend FeLV/FIV testing PRIOR to starting tx (if status unknown)
For OUTDOOR cats…
= TOXOPLASMA TITERS FOR OUTDOOR CATS to see if EXPOSED to toxoplasma –> more likely for systemic infection
–> TOXOPOSITIVE CATS NOT AT INCREASED RISK FOR TOXOPLASMOSIS
–> TOXONEGATIVE CATS only at risk if NEWLY INFECTED with toxoplasmosis while on CycA –> DON’T ALLOW THEM TO HUNT
describe the location & nature of the lesion
reaction from WHAT drug is likely?
HYPERKERATOTIC NASAL PLANUM
reaction from CYCLOSPORINE A (long-term use)
describe the location & nature of the lesion
reaction from WHAT drug is likely?
GINGIVAL HYPERPLASIA
reaction from CYCLOSPORINE A (long-term use)
